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Home , Olecranon bursitis, Therapeutic ultrasound

Case Report

Ultrasound therapy for recurrent noninfective olecranon : A case report

S. Aswinprakash, D. Jagadeesh, R. Arulmoli, Yuvaraj Maria Francis1, Kaviarasu Mahalingam2, Robert Francis Stanley3, Diwakar Aiyaloo4 Anatomy Unit, Faculty of Medicine, AIMST University, 2Physiotherapy Unit, Faculty of Allied Health Professions, AIMST University, 3Physiology Unit, Faculty of Medicine, AIMST University, 4Biochemistry Unit, Faculty of Medicine, AIMST University, Bedong, Kedah, Malaysia, 1Department of Anatomy, Saveetha Medical College, Thandalam, Chennai, India

Abstract Olecranon bursa is the commonly involved structure of the joint in trauma of any mechanical cause or due to its subcutaneous position. The overall incidence may vary, but it is more common in males between 30 and 60 years. Various pharmaceutical and physiotherapeutic treatment options are available based on septic or nonseptic conditions. Mostly and nonsteroidal anti‑inflammatory drugs are widely used by physicians, whereas electrotherapy modalities are the choice of treatment by physiotherapists. Among which, (US) therapy is found to be more convenient and effective in treating bursitis. As of the recent evidence available, US therapy is highly effective in treating olecranon bursitis.

Keywords: Bursitis, elbow, olecranon, orthopedics, trauma, ultrasound therapy

Address for correspondence: Mr. S. Aswinprakash, Lecturer, Anatomy Unit, Faculty of Medicine, AIMST University, Semeling Bedong, Kedah, Malaysia 01800. E‑mail: [email protected]

INTRODUCTION is not certain; it typically affects men between the ages of 30 and 60 years.[8,9] Nearly two‑thirds of cases were noninfectious Olecranon bursa is a thin fluid‑filled sac located at the tip types,[10] and usually, it is a sterile that develops of the elbow joint.[1‑3] This superficial bursa usually develops secondary to any acute, occupational, or recreational trauma, between 7 and 10 years of age.[4] The floor of the olecranon crystal deposition like , and systemic autoimmune bursa lies on the triceps and olecranon, and the roof diseases such as rheumatoid and systemic lupus is loosely connected to the overlying skin of the elbow.[5] The erythematosus. Most cases of nonseptic bursitis are function is to prevent the friction between the olecranon posttraumatic or due to overuse injuries (repeated minor process and the subcutaneous tissues during both flexion and trauma due to sports) or direct trauma. This causes bleeding extension of the elbow joint.[6] The location of this bursa itself within the bursa or release of inflammatory substances. makes it more prone to any kind of trauma or . The term olecranon bursitis is represented using various terms In the conservative management, anti‑inflammatory such as swollen elbow, student’s elbow, and Baker’s elbow.[7] and medications were prescribed based on the severity. Adjunct to that, various modalities such as The clinical features are characterized by pain, swelling, and inflammation at the point of the elbow. The overall incidence This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to Access this article online remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Quick Response Code: Website: For reprints contact: [email protected] www.jpionline.org

How to cite this article: Aswinprakash S, Jagadeesh D, Arulmoli R, DOI: Francis YM, Mahalingam K, Stanley RF, et al. Ultrasound therapy for 10.4103/jphi.JPHI_4_19 recurrent noninfective olecranon bursitis: A case report. Int J Pharma Investig 2018;8:205-9.

© 2019 International Journal of Pharmaceutical Investigation | Published by Wolters Kluwer - Medknow 205 Aswinprakash, et al.: Ultrasound therapy for recurrent noninfective olecranon bursitis: A case report cryotherapy, taping techniques, compression, and optimal He was prescribed with nonsteroidal anti‑inflammatory elbow positioning and padding have been done to promote drugs (NSAIDs) and analgesics by an orthopedic surgeon the healing. Aspiration, corticosteroid injection, and who attended him initially, with a follow‑up of one month surgical drainage and excision are only considered in severe and no further significant improvement, aspirations and two and recurrent cases. corticosteroid injections were administered into his affected left olecranon bursa; adhesive bandage was applied over the Ultrasound (US) therapy is one of the electrotherapy point of the elbow without any immobilization of the joint. modalities used in physiotherapy for treating inflammatory This made a temporary resolution of the condition, but conditions,[11] in which electrical energy is converted into the swelling appeared in the posterior elbow after 2 weeks. acoustic energy by means of deformation of piezoelectric crystal present within the transducer. Therapeutic US Laboratory investigations were done, and the fluid culture administered over the tissues will be having thermal and turned to be negative and all markers were in the normal nonthermal effects. Thermal effects aid in pain relief, range. The patient refused for any further invasive surgical whereas nonthermal effects enhance cell repair.[12] The procedures and referred for the physiotherapy management physiological effects had been proved and commonly to New Life Hospital, Chennai. During the assessment, the used for the soft‑tissue injuries and associated rheumatic physical examination of the left elbow point showed an complaints.[13] This case report presents a unique treatment average of 5.5 cm and bounded mass over the olecranon for recurrent noninfective olecranon bursitis using US process without any tenderness, redness, or warmth. therapy. After the failure of conservative management, Goniometric active and passive range of elbow flexion a patient with recurrent nonseptic olecranon bursitis was and extension in the affected elbow was normal (0°–120°). treated with US therapy and completely recovered. This The movements at the radioulnar joint (supination therapy provided a safe method without creating any and pronation) were normal. There was no abnormal discomfort for the patient. It could be considered as an neurological involvement. No spasm or wasting of the attractive treatment option for chronic nonseptic olecranon muscles was observed. bursitis. The radiographical findings revealed the soft‑tissue CASE REPORT enlargement over the olecranon process without any kind of fracture or abnormal bony growth. Based on the overall A 22‑year‑old healthy man, who is a regular basket ballplayer, clinical status and the fixed condition, it was diagnosed presented the complaints with left posterior elbow swelling, as recurrent noninfective olecranon bursitis. The patient pain, and discomfort for nearly 6 months [Figure 1]. He expressed and preferred his interest in trying physiotherapy had a history of elbow trauma by hitting the point of the management using electrotherapy modality. The decision elbow directly against the concrete floor of the basketball was made with US therapy and informed the patient about court, as a result of falling during sports activity. The pain the procedure. tends to increase during rest at the affected elbow. He continued to play basketball and is able to do functional Chattanooga brand US machine with the transducer head activities with a lesser pain and discomfort. However, he size of 5 cm2 was used for treating this patient [Figure 2]. denied any paresthesia around the elbow or weakness.

Figure 2: Therapeutic ultrasound with plugged in transducer and Figure 1: Olecranon bursitis of the left elbow coupling media

206 International Journal of Pharmaceutical Investigation | Volume 8 | Issue 4 | October-December 2018 Aswinprakash, et al.: Ultrasound therapy for recurrent noninfective olecranon bursitis: A case report Effective radiated area was selected around the tip of the whirlpool (40.6°C) raised the temperature 1.1°C; however, elbow at the site of swelling with their adjacent margins; at this same depth, 3‑MHz US raised the temperature 4°C after sterilizing the treatment area, coupling media were in 4 min. Thermal effects of the US over the body tissues applied over the affected site and the transducer head. The cause an increase in circulation, reduction of muscle transducer was moved in a circular and longitudinal pattern spasm, and extensibility of collagen fibers.[17] In a study over the site of swelling and its boundaries. The of of done by Dyson et al., nonthermal effects of the US 3 MHz in continuous mode with a ratio of 1:1 and intensity are the , in which the microstreaming causes of about 0.5–0.8 W/cm2 was employed. The duration of the increase in flow of surrounding fluid. This kind of the treatment was 5–10 min every other day. The patient effect will reduce the swelling. Nonthermal effects occur attended 14 sittings for the therapy with progressive changes, when pulsed US is applied. Nonthermal effects are useful and complete resolution was achieved grossly during the for decreasing and promoting cellular repair. The final stages of therapy. Posttreatment evaluations were above‑said changes are the result of the chemical, biologic, done in a regular follow‑up of 2 weeks, 1 month, 2 months, mechanical, and thermal effects of the sound waves.[18] and 6 months. He continued to report with no recurrence, and physical examinations showed neither swelling nor Physiological effects of US are considered to increase discomfort around the point of the elbow. There was a in collagen extensibility, increases the nerve conduction complete pain‑free range of motion of the elbow joint, and velocities, increases the metabolism of edema and exudates, the patient was satisfied with the outcome. decreases joint stiffness, increases pain threshold, decreases muscle spasm and releases histamine. The indications of US DISCUSSION therapy are soft‑tissue injuries, myositis ossificans, chronic and joint dysfunction, nerve entrapments, Recurrent noninfective olecranon bursitis will be osteoarthritis, plantar warts, periarthritis (nonseptic), exasperation for the patients and the physicians who are chronic and strains, , muscle spasm, managing the condition. Sometimes, there will be disability tendonitis, bursitis, and capsulitis.[19] ranging that will alter the functional activities of daily living. The reason is because of increase in the inflammatory fluid It was demonstrated that there is a direct relationship within the bursa. The swelling around the point of the elbow between the absorption of US and the amount of protein is considered in a cosmetic point of view. Even though in the tissue, and when the concentration of protein a wide variety of NSAIDs available and various invasive increased, the absorption of US increased. In normal surgical interventions such as bursectomy as the choice of tissue, the absorption of US energy varies depending on the treatments the recurrence after all these measures will be amount of protein in the tissue.[20] Love and Kremkau et al. a frustrating factor for the physician as well as the patient. demonstrated that there is a direct relationship between the absorption of US and the amount of protein in the In a study of Stasinopoulos et al., US is one of the modalities tissue, and when the concentration of protein increased, used by those physiotherapists daily in their clinical practice. the absorption of US increased. In normal tissue, the There are strong evidence that support US for producing absorption of US energy varies depending on the amount positive effects on soft‑tissue healing.[14] Similar effects have of protein in the tissue, they removed extracellular tissue been observed on animal studies as well.[15,16] Scientifically, structures such as collagen, fibrin, and elastin, and then it has been proved that the effectiveness of US was based placing only the cells in tissue culture media maintained on its parameters: frequency, mode, intensity, duration of at 37°C, they could treat cells at therapeutic levels without treatment, the way the transducer head was moved during significant increases in temperature <0.5°C for >10 min.[21] the treatment, coupling medium, treatment intervals, and effective radiated area. The application of US during the inflammatory, proliferative, and tissue repair stages is not only of value because it changes In a study of done by Draper and Prentice, US is a the normal sequence of events but also because it has the deep‑heating modality. Acoustic microstreaming is capacity to stimulate or enhance these normal events and defined as the physical forces of the sound waves that thus increase the efficiency in the healing stages.[22] During provide a driving force capable of displacing ions and the inflammatory phase, US has a stimulating effect on the small molecules. At a soft‑tissue depth of 3 cm, a 10‑min mast cells, platelets, white cells with phagocytic roles, and therapy induces an increase of 0.8°C, and 1‑MHz US macrophages.[23] The US application induces degranulation has raised the temperature nearer to 4°C by 10 min, of mast cells, causing the release of arachidonic acid which whereas by 1 cm below the fat surface, a 4‑minute warm itself is a precursor for the synthesis of prostaglandins and

International Journal of Pharmaceutical Investigation | Volume 8 | Issue 4 | October-December 2018 207 Aswinprakash, et al.: Ultrasound therapy for recurrent noninfective olecranon bursitis: A case report leukotriene which in turn act as inflammatory mediators.[24] acute and chronic soft‑tissue pathologies similar to the US has a stimulative effect during the proliferative phase and above‑mentioned condition. scar production through the fibroblasts, endothelial cells, and myofibroblasts. Therefore, US does not change the normal Declaration of patient consent proliferative phase but maximizes its efficiency – producing The authors certify that they have obtained all appropriate the required scar tissue in an optimal fashion – and low‑dose patient consent forms. In the form the patient(s) has/have pulsed US increases protein synthesis, and several research given his/her/their consent for his/her/their images and groups have demonstrated enhanced fibroplasia and other clinical information to be reported in the journal. collagen synthesis.[25] The therapeutic application of US The patients understand that their names and initials will influences over the remodeling of scar tissue by enhancing not be published and due efforts will be made to conceal the appropriate orientation of the newly formed collagen their identity, but anonymity cannot be guaranteed. fibers, increasing the viscoelastic property, and enhancing scar tissue mobilization.[26,27] Financial support and sponsorship Nil. Regarding the effectiveness of US, Robertson and Conflicts of interest Baker concluded that there are little evidence that US There are no conflicts of interest. was very effective than placebo for treating people with musculoskeletal conditions or for promoting soft‑tissue REFERENCES healing. There are few studies deemed to have adequate methods examined a wide that range of patient problems, 1. Shell D, Perkins R, Cosgarea A. Septic olecranon bursitis: Recognition the dosages used in these studies varied considerably, often and treatment. J Am Board Fam Pract 1995;8:217‑20. [28] 2. Ho G Jr., Tice AD, Kaplan SR. Septic bursitis in the prepatellar and for no discernable reasons. Indeed, some of the studies olecranon bursae: An analysis of 25 cases. Ann Intern Med 1978;89:21‑7. from review could not draw a definitive conclusion because 3. Reilly JP, Nicholas JA. The chronically inflamed bursa. Clin Sports of insufficient evidence. 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